Cardiology Case Study - 10

Cardiology

TAPE 8B, Report 10

DISCHARGE SUMMARY

PROVISIONAL DIAGNOSIS

Labile hypertension with transient focal neural symptoms.

FINAL DIAGNOSIS

Labile hypertension with transient focal neural symptoms.

OPERATIONS

None.

HISTORY

This is a 49-year-old white male with a 2-year history of episodes of lightheadedness, 18-month history of extreme fatigue, a 1-year history of funny feeling in his right arm and numbness in his face, and a 2- to 3-month history of labile emotions and episodes of crying.  Patient has been evaluated by an ear specialist in the past with no findings suggesting a central nervous system lesion.  Patient had been hospitalized before for exhaustion.

PHYSICAL EXAMINATION

His blood pressure was 150/105.  Pulse, respirations were stable.  Patient was alert and oriented and did not appear to be in any distress.  HEENT was within normal limits.  Cardiovascular and respiratory were also within normal limits.  Neurologic showed no focal deficits at this time.  Deep tendon reflexes were equal bilaterally.

LABORATORY DATA

Appropriate laboratories ordered, with elevation noted in cholesterol only.  UA, thyroid function test, CBC, ECG, chest
x-ray, and a CT of the head were all performed and were all within normal limits.

HOSPITAL COURSE

Patient’s course in the hospital was fairly uneventful, with occasional episodes of lightheadedness and disequilibrium associated with a rise in diastolic blood pressure above 100.  Patient was discharged on Procardia 20 mg t.i.d. for blood pressure and was given containers to collect urine for further testing.  There were also some laboratory results, total catecholamines, which were not completed at this time.

PROGNOSIS

Good.

FOOTNOTE

Line 11 (Page 1).  The dictator indicates that the Final Diagnosis is the same as the Provisional Diagnosis.  For clarity, the Final Diagnosis is repeated in full.

Line 32 (Page 1).  Bilateral was changed to bilaterally for proper adverb use.

Line 40 (Page 1).  The heading Hospital Course was added.

Line 46 (Page 1).  There was was changed to There were for correct subject-verb agreement (There were ... results).